The NewsHour with Jim Lehrer

JIM LEHRER: Good evening. I'm Jim Lehrer. On the NewsHour tonight, Spencer Michels, Margaret Warner and Gwen Ifill take us through the news and the controversy about the world trade talks in Seattle; Susan Dentzer and Ray Suarez examine a new report about medical mistakes; and Elizabeth Farnsworth talks with the winner of the National Book Award for fiction. It all follows our summary of the news this Tuesday.

NEWS SUMMARY

JIM LEHRER: Police and protesters clashed today in Seattle, forcing cancellation of the World Trade Organization's opening ceremonies. Thousands of demonstrators jammed downtown streets. They set up barriers, tied up traffic, and blocked access for trade delegates from 135 member nations. Police fired pepper spray and teargas and made a dozen arrests. Labor groups staged a peaceful march several blocks away. At the White House, President Clinton expressed his aims for the talks.

PRESIDENT CLINTON: I hope we'll get a new round launched that will slash tariffs and other trade barriers in agriculture and other areas. I hope we will agree to keep e-commerce free of unusual burdens and that we will lead to more transparent and open rules among nations so they believe the trading system is fair. I also strongly, strongly believe that we should open the process up to all those people who are now demonstrating on the outside. They ought to be part of it. And I think we should strengthen the role and the interests of labor and the environment in our trade negotiations.

JIM LEHRER: The President flew to the West Coast today; he will address the conference in Seattle tomorrow. We'll have more on this story right after the News Summary. Before his departure, Mr. Clinton called for a new effort to curb fatal medical mistakes. He was responding to a report by the Institute of Medicine that said up to 98,000 Americans die each year from such errors. It cited prescription drug mistakes as a major cause. The quasi-public agency urged Congress to set up a mandatory reporting system for serious medical mistakes. It also asked providers to aim for a 50 percent reduction in errors over the next five years. We'll have more on the story later in the program tonight. Twenty-two Americans are believed to be among the more than one hundred bodies found buried in Mexico, authorities said today. Mass graves were found on two ranches about ten miles south of the border cities of Juarez, and El Paso, Texas. Mexico's attorney general said he believed the victims were killed by the Juarez Drug Cartel. FBI agents were assisting Mexican authorities. President Clinton said the killings were a horrible example of the brutality of the Mexican drug cartels. In El Paso, the FBI briefed reporters late this afternoon.

DAVID ALBA, FBI: During the past four years and possibly longer, citizens of both countries have disappeared without a trace. Investigators from the Republic of Mexico have been conducting investigations into these alleged drug-related disappearances. Simultaneously, investigators of the FBI at El Paso, Texas, have been conducting investigations into the drug-related disappearances of U.S. citizens. Through the request of the Republic of Mexico, the FBI has provided evidence recovery resources in order to assist the PGR in the humanitarian effort of the recovery of remains of missing Mexican and U.S. citizens at two locations near Jaurez, Mexico.

JIM LEHRER: President Clinton offered a plan today to give parents paid time off to care for newborn or newly adopted children. The money would come from state unemployment insurance funds, leaving states to decide how much leave to offer and how much to pay. The voluntary plan would take effect early next year. Parents are already entitled to take up to 12 weeks of unpaid leave under federal law. But Mr. Clinton said too many people can't afford to take time off without pay. The Federal Trade Commission approved the merger today of Exxon and Mobil Oil Corporations. The $81 billion deal will create the world's largest non- government petroleum company. The FTC will require the two firms to sell more than 2,400 service stations in areas where they have large overlapping retail markets. The combined company will be called Exxon-Mobil Corporation. And that's it for the News Summary tonight. Now it's on to the world trade talks in Seattle; medical mistakes; and the National Book Award winner for fiction.

FOCUS - TALKING TRADE

JIM LEHRER: Spencer Michels begins our trade report.

SPENCER MICHELS: The controversy over world trade policies grew heated today, as police fired pepper spray to disperse a crowd of anti-trade demonstrators. They were protesting outside the Seattle Conference Center and Theater wherethe World Trade Organization, the WTO, was meeting. The demonstrators prevented many delegates from getting to the opening ceremonies, which were canceled late in the day. The protests outside, involving thousands of uninvited guests, challenge a fundamental assumption of the WTO: That an increasingly global economy has more pluses than minuses. The critics say unrestricted free trade tramples on workers' rights by making them compete with lower paid workers, and that it endangers the environment by overriding individual countries' strict environmental regulations on items like clean air. Yesterday, the WTO'S director general responded.

MIKE MOORE, Director General, WTO: The WTO is not a world government, a global policeman, or an agent for corporate interests. It has no authority to tell countries what trade policies or any other policies they should adopt. Put simply, the WTO is not a super-national government and no one has any intention of making it one.

SPENCER MICHELS: The trade body's origins date back to 1944, when world leaders met in Breton Woods, New Hampshire, toward the end of World War II. They laid the foundations for the World Bank, the International Monetary Fund, and the precursor to the WTO, an organization known as the General Agreement on Tariffs and Trade. GATT was a forum for countries to negotiate lower import taxes, or tariffs, in the belief that more trade helps the worldwide economy. In 1995, the GATT expanded the scope of its oversight, set up headquarters in Geneva, Switzerland, and became known as the WTO. In the last five decades, the trade body has grown from 23 to 135 members. At least 30 countries, including China and Russia, are negotiating to join the club. Since the 1940's, average tariffs in WTO countries have fallen from 40 percent to around 5 percent and world trade has grown fourteenfold. Among the key missions of the modern-day WTO is overseeing commerce in several areas, including goods, such as automobiles, services like banking, and intellectual property, including patent rights. The group is also a forum for settling trade fights. This year's meeting has no formal agenda. Delegates failed to reach one last week. Still, several contentious issues are likely to receive much attention, like buying goods on the internet and how long it will remain tariff-free; European and Japanese subsidies of farm exports, which competitors say gives those nations an unfair advantage; European import limits on genetically modified food from the U.S, considered by critics just an excuse to curtail perfectly healthy American imports; and U.S. policies designed to protect domestic steel makers from what they consider "dumping," the export from other countries of artificially low-cost products. President Clinton speaks at the conference tomorrow. Last week he failed to persuade other world leaders to join him in Seattle and come up with an agenda for this week. But today's delayed start gives WTO Ministers even less time to resolve their differences by Friday. If they do agree on a framework for moving forward, then a new round of bargaining-- negotiations that would last several years-- can begin.

JIM LEHRER: And to Margaret Warner.

MARGARET WARNER: Joining us from Seattle for an update on the WTO meeting is David Sanger, economic correspondent for the "New York Times." Well, David, is it as wild out there as the television footage suggests?

DAVID SANGER, The New York Times: Well, it's pretty wild, Margaret. The demonstrations started early this morning, and they succeeded in delaying, really canceling the morning sessions of the meeting, because the American delegation was holed up in its hotel and couldn't get out, and the Europeans were holed up across town in their hotel, and the result is a significant amount of disruption. I'm not sure what that will add up to by the time this is all over, but certainly for the day, the demonstrators got their point across.

MARGARET WARNER: This certainly isn't your typical international trade ministerial, of which you've attended many. How did this one become such a flash point?

DAVID SANGER: Well, it's an interesting question, Margaret. Five years ago when the WTO started, it was hard to get a group of reporters to something like this, much less a group of demonstrators. I think that there are two things that have made the WTO a particular focal point for all of these groups. The first is that it seems as if it is a symbol of world government to many, because it has a power, of course, to rule on the international legality of individual countries' rules about trade and all of the issues that that raises. But I think the second issue is that trade these days seems far broader than just the movement of products across borders. It has come to involve the question of what are the environmental standards of countries that are shipping those products, how do they treat their workers, and these are all priorities that the people you see out on the street want to make an integral part of trade negotiations, whereas the WTO itself, of course, was created not to deal with those issues, but just to promote free trade and lower barriers. So what they're trying to do here, what you're seeing happen on the streets is a conflict between the old think about trade, which is that it's a fairly narrow set of economic issues, and the new think, which is it is related to all of these other questions. And on that, you see both countries and companies dividing.

MARGARET WARNER: Now, the trade negotiators, the sort of pre-meeting negotiators in Geneva last week weren't even able to come up with a formal agenda. Was that because of, to use your phrase, the old-think considerations or the new-think considerations or both?

DAVID SANGER: Well, a little bit of both, Margaret. In Geneva, you had basically a group of trade negotiators and trade bureaucrats who were trying to come up with the agenda that they would then hand to their ministers to get going what is called a trade round. And of course, this would just be the beginning here of a three- or four-year process of negotiating a reduction in barriers. They could not even come to an agreement about what issues should be debated. The Europeans, of course, don't want to have the issue of their food subsidies on the table, or at least on the table in a way that they think would lead to major reductions. The Japanese want to review the American dumping... anti-dumping actions, that is the steps the United States takes to keep out products it thinks are unfairly low in their prices. The result of that is that the U.S. and Japan were at loggerheads on these issues. The developing countries don't want many of these labor issues to come up because they're afraid the United States and the WTO will be dictating to them about what the standards should be inside their factories.

MARGARET WARNER: And then President Clinton had hoped to get some other world leaders to join him out there, what, to help break these impasses, but to no avail?

DAVID SANGER: That's right. The White House sensed that to break this deadlock, you are going to need some political decisions made by political decision makers. So they sent out feelers to the likes of Jacques Chirac in France, to leaders in South Africa, and the Japanese prime minister, Prime Minister Obuchi. All of them said, "well, you're doing this at the very last moment, and we can't come because of our tight schedules," and I'm sure that probably explained why many of them couldn't come. But also, I think, many of those leaders realized that these have become the hot-button issues inside their countries, and they really did not want to be associated with the start of this negotiating round.

MARGARET WARNER: Now, what is the administration's game plan -- I know you've been talking to these people for weeks now about this, for dealing with the hot- button issues that the demonstrators are presenting, that is mostly the labor and environmental issues that they want put on the formal agenda?

DAVID SANGER: Well, the administration's plan for labor was to just try to get a working group going within the WTO That would just get this subject discussed for the first time. It's never been discussed within the WTO The developing countries led by India have been objecting to this because they realize it's a slippery slope. As soon as the WTO begins discussing these issues, then they've been legitimized within the forum of the World Trade Organization. It's only a matter of time before they become integrated into the agreements. The Europeans have come up with an interesting alternative, which is to create a working group that is partly between the WTO and the international labor organization, which is a fairly toothless group, also in Geneva, that until now has issued the regulations on these issues. That seems to have some more appeal to some countries, but there are many countries that don't even want to discuss in that jointly run group.

MARGARET WARNER: So briefly before we go, the president today did say he sympathized with the demonstrators, but how far do you think the administration, or does your reporting tell you the administration's really ready to go in trying to push their agenda?

DAVID SANGER: The administration would like to push their agenda, and they certainly want to show that they are pushing it, because it is a very important issue for vice president gore. Imagine two major democratic constituencies here, labor and the environmentalists, are terribly angry at the administration for its inability and, in their mind, its unwillingness to really push these issues to the center of the stage. I think you'll hear President Clinton talk in very sympathetic terms with the demonstrators and about their issues. Whether that translates into much progress for him on those issues, that seems somewhat doubtful right now.

MARGARET WARNER: All right, David. Thanks very much.

DAVID SANGER: Thank you, Margaret.

JIM LEHRER: And that takes us to a debate about the WTO and to Gwen Ifill.

GWEN IFILL: We are joined from Seattle by Thomas Donohue, the president of the U.S. Chamber of Commerce, and Lori Wallach, director of Public Citizens' Global Trade Watch, a nonprofit citizen research, lobbying, and litigation group; and here in Washington by Daniel Tarullo, professor at Georgetown University Law Center, and former assistant to President Clinton for international economic policy; and Kevin Kearns, president of the U.S. Business and Industry Council, a Washington research and lobbying group which represents some small and mid-sized businesses. Mr. Donohue, we've been seeing all day about the protests which have been building in Seattle, and we wonderif they're getting all the play and there is something more important that's been overlooked.

THOMAS DONOHUE: I think it's interesting to be in Seattle. Most of the protesters that I have seen personally, including the union organizations, are very orderly and they're about their business and they're carrying on their arguments. There are a group of thugs that are walking around the streets, crashing in windows and turning over paper stands and other things, and they ought to take those people off the street. I respect the position of unions and others to demonstrate, and it certainly will draw the attention of the people that are here doing the serious business of world trade.

GWEN IFILL: As the leader of the Chamber of Commerce, you obviously believe there's a greater good involved in the WTO. What's your point of view on that?

THOMAS DONOHUE: Well, it's a very simple issue that 96 percent of the people that we want to sell things to live outside the United States, and the great proportion of our economic growth has been tied to world trade. There are things that need to be improved, but it is very clear that the lives of people around the world and their freedoms have been improved and extended because of exchange and trade, and that the United States is benefiting every day from our position in the world economy, and we ought to do more of it and continue the benefits that are available for our citizens at every level of our society.

GWEN IFILL: Mr. Kearns, you're obviously of the absolutely opposite point of view. You believe that we should be pulling out of the WTO Entirely. Why is that?

KEVIN KEARNS: Yeah, that's right. I think what Mr. Donohue said is absolute nonsense. The WTO was set up about eight years... well, the theory of it, et cetera, came about eight years ago at the beginning of the Clinton administration. The Reagan administration, the Bush administration wouldn't touch it. And the theory was the U.S. economy wasn't going to grow at all, and the only way we were going to grow was selling goods into these big emerging markets. Absolutely opposite has turned out to be the case. The U.S. economy has been the world engine. It is our domestic economy, not our exports, that are driving growth in this country, and other countries have hitched their wagon to our star. Now, the thought was we needed the WTO to open these big emerging markets, but in fact most of the people, the 96 percent of the world's population that lives outside the United States, doesn't have any money. They may be consumers in a theoretical sense, but practically they don't have the money to buy American products. So our point of view is that we want more trade, we want open trade, we want fair trade. The best way to accomplish that is not through an international bureaucracy, but simply by bilateral negotiations with other countries, and allowing them to have access to our market as long as we have free and fair access to their markets.

GWEN IFILL: Ms. Wallach, you believe that there are many sticking points, including labor and environmental concerns and human rights concerns. What could happen to make this palatable for you and for Public Citizens'?

LORI WALLACH: Well, the World Trade Organization isn't free trade, which would be basically cutting barriers; it's 900 pages of one version of rules for the global economy. In some areas it cuts barriers, but some of those barriers are our domestic food safety or environmental laws. In other places, it adds new barriers. For instance, being from a consumer group, we're concerned about access to medicines, and the WTO adds restrictions on trade in medicines, and in a way that keeps the prices up. So what we say is, this is managed trade, it's not free trade. But the rules are very lopsided, and it's really corporate managed trade, and the public interest is continually put under the goal of commerce. So, for instance, in five years at the WTO, there's a whole string of laws. The U.S. now has to accept Australian meat that's not government-inspected. It's "equivalent" under WTO; it's labeled U.S.D.A. The U.S. Clean Air Act's regulations were weakened after a WTO attack. The tuna/dolphin law that has kept the tuna fish in our country from being caught with dolphin-killing nets was ruled WTO illegal, and we gutted that law -- the Endangered Species Act. And those are just the U.S. laws. Around the world it's been a real-life record of unacceptable and unnecessary damage. We want global trade rules, but this WTO and its 18 different sets of agreements has got to get dramatically changed, or it has to go.

GWEN IFILL: Mr. Tarullo, is that part of the problem here, that there is too much trying to crowd under the WTO umbrella?

DANIEL TARULLO: I think that's exactly the problem. In your setup piece, David Sanger made reference to old think and new think about trade. One of the problems is that under the old-think umbrella, a lot of issues were pushed into the WTO that are really not about taking down trade barriers at the border. They are, as Lori Wallach just said, about domestic regulation. And when you start to tell countries that here's how you must do your domestic regulation, and you're telling them that under the aegis of export-oriented interests, I think you're just setting yourself up for a big set of political problems. And that's what we've seen.

GWEN IFILL: What about, that Mr. Donohue? It sounds like a pretty insurmountable mishmash of different issues, all of which could cancel each other out.

THOMAS DONOHUE: Well, a lot of what I just listened to is a little bit like a fairytale. It's very clear that the WTO tries to establish standards and resolve disputes, but they do not and they cannot force any country to change its domestic rules. It is also a basic fact that the United States is the largest exporter in the world, and for every 20,000...for every $1 billion worth of exports, we create 20,000 American jobs. The WTO is not a government. It has no authority over the United States, or for that matter any of its other 135 members. It is an organization that is trying to figure out a way to put rules of trade in place that are acceptable on a consensus basis and that lets Americans get a reduction in barriers around the world-- that's where we see the benefit-- and some order. When you talk about bringing the Chinese into WTO, there are a lot of benefits, but the biggest benefit is they're asked to run their trading operations under a set of agreements that 135 nations have sat down and said that generally they're going to try to operate under consensus. There are problems with every trading system, but the bottom line is we're making significant advancement. We're the largest exporter in the world. We are increasing the standard of living of people all around the world by trading, and you know, I'm just not sure where all of this sort of fantasy comes from that we're changing everything and ruining everything in this country by dealing with the WTO; it is not a fact. We ought to get the facts a little straighter, and then we can find some common ground to resolve what we're here for. We're here to puttogether the next level of trading discussions. That's what we need to accomplish.

GWEN IFILL: Pardon me, but Mr. Tarullo here is champing at the bit to respond.

DANIEL TARULLO: Well, I'd just like to say that if it's about trade and tariff barriers, I don't have any quarrel with Mr. Donohue. But I think it's a little misleading to say that we're not asking anyone to change their domestic rules. Even though in a technical sense no one gives up sovereignty by joining the WTO, in a practical sense, you are, in negotiations, being asked to change your rules. Now, sometimes that's perfectly okay. But when you have conflicts between trade and non-trade values, such as whether a particular food safety regulation ought to be permitted, then inevitably a dispute settlement panel in Geneva is called upon to balance trade and non-trade considerations, and I think it's there the WTO gets into trouble, not breaking down quotas, not breaking down traditional tariffs, but in talking about food safety regulation and talking about health, endangered species regulation. There are a number of instances where nondiscriminatory regulations are being attacked by other countries as trade barriers, and I think it's there the WTO courts trouble for itself and undermines its own aim of promoting liberal trade.

GWEN IFILL: Mr. Kearns, you have said that part of your concern about this is that this is all about the political and economic interests of the countries involved. What's wrong with that?

KEVIN KEARNS: Well, it's a political and economic interest of various countries, sure. We have to live in a multipolar world and mediate our way. But the fact of the matter is we did quite well up until four years ago when the WTO was created. We have had a globalized trading system, if you will, since the Portuguese rounded the southern cape in Africa. America itself is a result of an attempt to further expand the global trading system. And as Lori Wallach has pointed out, the real question is how do we manage this system? Is the WTO the vehicle to manage this system, or are there better ways to manage this system? And I think it's... Mr. Donohue seems to specialize in fantasy and know a lot about it. I think it's a utopian fantasy to think that the 133 members of the WTO are part of a global system in the sense that they have the same political values, economic values, cultural values. The Chinese certainly don't share many of our values. Allowing them to come into the WTO -- that in itself could destroy the WTO, because they simply have broken every major trade agreement they have signed in the last 20 years. There's no reasonable expectation they will abide by the so-called rules in the WTO.

GWEN IFILL: Ms. Wallach, how does one manage this?

LORI WALLACH: Well, what we have seen, and despite what Mr. Donohue said, the five-year record of what's actually happened is that a series of laws have been challenged under this system of rules and declared illegal trade barriers. The asbestos ban, it was treating domestic and foreign products alike. Why should the WTO, an unelected body, impose its choice that you can't ban asbestos? So that invasion of all these new areas is where the WTO needs to be drastically pruned back. And my sense of what will happen... and by the way, I think the reason why there are so many diverse protesters from all over the world and from all over the U.S. is people find the results of this deregulatory agenda attached to the trade rules as totally unacceptable. And so either the WTO is going to get drastically pruned back, more like the old GATT system, or alternatively it's going to get...end up getting gutted. At some point, some big, important law, the ban on child labor-- which by the way is WTO-illegal-- is going to get challenged, and that's going to be the end of it. And the arrogance or the stubbornness of the people who are benefiting from this system of rules stands to blow up the whole thing. And we need global trade rules, but this WTO needs to be drastically pruned back, or it needs to be replaced.

GWEN IFILL: Mr. Donohue, one of the things that you have said seems to leave room for very little room for compromise on some of these things, which is to say labor and trade standards. You said the chance that the U.S. would tie trade and environment and labor standards to trade is that it won't happen even if "the U.S. stands on its head and spits wooden nickels." Where is there room for middle ground?

THOMAS DONOHUE: Unfortunately, "Time" magazine, with whom I spoke for a very long period of time, left out the first paragraph.

GWEN IFILL: Which is?

THOMAS DONOHUE: Which was that Mr. Sweeney and I had agreed on, through the action of the President's trade advisory group, to advance a new working group within the WTO which I am trying very hard to have accepted, which would be the 49th working group, and it would be to analyze the effects of trade on workers in the United States and workers around the world. But it would not be coupled to a particular trade negotiation. It would be a valuable and professional analysis of what trade on its own, global trade, was doing for workers here and around the world. I said, however, following that, "but to expect that at this meeting that we would accept a coupled agreement where we wouldn't come to any understandings on trade until we had done this analysis, would not happen, and it wouldn't happen if we wanted it to happen, and I stood on my head and spit wooden nickels." And I really believe that it's unfortunate that, having made an agreement with labor, that magazine that has been very pro- labor left out the first part of what I had to say.

GWEN IFILL: Well, I'll give you the last word on this if you can answer the same question that I just posed to Lori Wallach, was how can this be managed?

THOMAS DONOHUE: Well, I think the whole thing is it's a consensus arrangement. And I believe there are some things that have to be changed. I believe that the WTO, as it brings in other countries, as it sophisticates its work, we have to limit the things we spend time and energy on. One of the great concerns I have is in the EURO -- they're setting up a series of obstructions, particularly to genetically altered agriculture and other issues with 75 million people more coming into the world every year to be fed. And I think they have to focus on these issues. I agree with some of the opponents that occasionally we get in to far too many extraneous issues. Let us focus on the matter of trade, but let us try and open up markets to the United States that have been closed in the past while our markets have been open to others.

GWEN IFILL: Thank you all very much.

JIM LEHRER: And still to come on the NewsHour tonight, medical mistakes, and the National Book Award winner for fiction.

JIM LEHRER: The new report on medical mistakes and what to do about them. We begin with some background from Susan Dentzer of our health unit, a partnership with the Henry J. Kaiser Family Foundation.

SUSAN DENTZER: "To err is human," goes the old saying, and that's a reality that much of U.S. industry adapted to long ago. Take the delivery company Federal Express. Even if Fed Ex delivered 99.99 percent of its packages on time, an error rate of 0.01 percent, an estimated 8 million packages a year would still arrive late. As a result, FedEx long ago adopted sophisticated computerized order entry and tracking systems. They're part of a company-wide effort to improve performance and eliminate as many mistakes as possible.

FED EX EMPLOYEE: Thank you. Have a good day

SUSAN DENTZER: Now a new report from the Institute of Medicine, an arm of the national academy of sciences, says America's health care industry has an urgent need to adopt some of these same quality-improvement practices. The report says that's because the error rate in medicine is unacceptably high. The report cited previous studies suggesting that mistakes in medicine injure as many as one million Americans each year and kill anywhere from 44,000 to 98,000. That makes medical mistakes a leading cause of preventable death that kills more people each year than breast cancer or motor vehicle accidents. Compiled by a group of leading health-care experts, the report cited instances of errors throughout the health system. Many involve mistakes in medication. Hospital staff may sometimes administer the wrong dose of a drug; that's what happened in the case of a Boston newspaper reporter killed by an overdose of chemotherapy in 1995. The causes are frequently simple but tragic, such as the inability of a nurse or other aide to read a physician's handwriting. The Institute's report called for comprehensive changes to improve patient safety. That means overhauling the way work is performed in many medical settings, such as adopting computerized order entry for drug prescribing and lab tests. In busy hospital emergency rooms, the report said, medications should be stored in the diluted forms in which they're administered to patients, rather than full- strength and potentially lethal. The report also called for the creation of controversial new systems to collect information on medical errors in hopes of finding ways to prevent them. Reporting would be mandatory in the case of mistakes that resulted in serious injuries or deaths, and voluntary in other instances.

JIM LEHRER: Ray Suarez takes it from there.

RAY SUAREZ: For more we're joined by Dr. Lucian Leape, a committee member of the institute that prepared the report. He is an adjunct professor at the Harvard School of Public Health. Dr. Nancy dickey, former president of the American Medical Association and past chair of the National Patient Safety Foundation. And Charles Bosk, a Professor of Sociology at the University of Pennsylvania. He is a senior fellow at the Leonard Davis Institute for Health Economics and author of the book "Forgive and Remember: Managing Medical Failure." Dr. Leape, let's start with you. For the purposes of your report, what was counted as medical error, and what was excluded?

DR. LUCIAN LEAPE: Well, medical errors include all the mistakes that people make from the trivial miscalculation of a dose of a medication to terrible things like cutting off a wrong leg and sort of everything in between. So we're talking about diagnostic errors, we're talking about errors in communication. We're talking about errors in writing a prescription. We're talking about the whole gamut of errors.

RAY SUAREZ: And given the fact that in real life sometimes we bury our mistakes, sometimes people work very hard to cover them up, how did you manage to count them?

DR. LUCIAN LEAPE: Well, different studies have used different methods. Most ofthe major studies have relied on reviewing information and records. And I think you bring an interesting point up. And that is all of them are not included. So some people think the problem is really even more serious than is indicated by those numbers.

RAY SUAREZ: Dr. Dickey, that suggestion that we set up a government-managed or government-sponsored mechanism for counting these errors, a place to report these errors, how would that sit with the members of a professional association like the AMA?

DR. NANCY DICKEY: Well, I think we clearly need to have a better database, as Dr. Leape points out, but creating a federal bureaucracy brings problems of its own. In fact, when we look at a perhaps parallel example, which is aviation, where they do have mandatory reporting, they discovered that in order for it to work, they had to have it separate from the regulatory agency. They had to be sure it was non-punitive, so that people would call in near misses, as well as problems, and they had to make sure that there was confidentiality. In fact, our government is the insurer for nearly 30 percent of Americans. Perhaps the reporting mechanism needs to be a public-private partnership, and clearly we'd have to answer some of the problems about confidentiality and non-punitiveness in order to make it work.

RAY SUAREZ: Well, if you were going to use that aviation model, and use that confidentiality, in effect you'd have doctors telling the government about things they did without telling their patients.

DR. NANCY DICKEY: Well, clearly we recommend to physicians that they sit down and talk to patients when there's been an error or a bad outcome, but I think we're talking about two separate pieces of the same puzzle, if you will. One has to do with trying to identify what causes an error so that you can change systems, change processes so that same error doesn't occur again. The other has to do with the trust that patients have that their doctor does the right thing and when something unexpected or unintended happens, communicates that to the patient and sets about trying to make it right or as right as one can at that point.

RAY SUAREZ: Professor Bosk, any physician is going to say, "what's our position on errors? We're against them." But as an ethicist, how would you enter cost into the conversation, so that we could have sort of an adult conversation about where it comes in?

CHARLES BOSK: Well, I think that's right. I think no one would be in favor of medical errors, and I think the report itself or what I've seen for the executive summary makes for terrifying reading in the sense that some of those errors seem random, and they could happen to anyone. What I worry about is that putting in place systems, and that certainly makes sense to Americas but doing that at a time when the rest of -- where we're cutting costs and the rest of the delivery system, so how do we balance the systems that we put into place with cost reduction, with major emphasis on controlling costs and medical care more generally, with less manpower in hospital systems -- I don't think that the systems that the report talks about are frictionless or costless. And the question is: If systems are going to have much less personnel in hospitals as they are, then how is this work going to be piggybacked onto already overworked workers?

RAY SUAREZ: Or conversely, do we have to concede that a certain amount of error is inevitable and rooting it out would be so costly that we just can't walk down that road.

CHARLES BOSK: Well, one of the problems for me is that we all understandably want medical care to be perfect, but I think we should recognize, as well, that no human endeavor is perfect, and what we haven't asked is what's optimal -- just how efficient can we expect an error-ridden, difficult, cognitively complex, manually complex, interdependent system like health care to be? And to the degree that some of those mistakes come from faulty miscommunication, I suspect that those errors may increase as we attempt to control costs. And while the goals of the report are laudable, and while everyone would be in favor of reducing error, I think we do need to raise the question of what are we willing to pay to do that, and what level of imperfection are we willing to tolerate?

RAY SUAREZ: Well, Dr. Leape, why don't you take it from there.

DR. LUCIAN LEAPE: Well, I think Dr. Bosk raises important questions. When we've studied it, we found that error reduction activities usually pay. People tend to underestimate how costly mistakes are. One of the reasons is that many of those costs are hidden. Patients bear the cost. We know, for example, that a serious, adverse drug event in a teaching hospital costs over $4,000. Now, that same hospital, which that study was done, put in a computerized physician order system that cost several million to develop, and yet by reducing the adverse drug effects by over 50 percent, they recouped that money in less than two years. So I think there's no question that some safety measures are going to cost money. But many of them will save money, and many of them would cost very little. For example, we know that every year a few patients are accidentally injured because they are injected with concentrated potassium chloride. The nurse thinks it's a different medication. That substance, potassium chloride, doesn't need to be available on the floor where the nurse can pick it up by mistake. Simply removing that substance from the nursing unit eliminates that particular hazard, and that doesn't cost anything. So there are a lot of things we can do, what we call the low-hanging fruit, the easy things that would make things a lot safer. But I would submit that some of them are going to cost money, and if we want safe care, we're going to have to pay for that. And I think most people would be willing to pay more to have it safer.

RAY SUAREZ: Dr. Dickey, I know real medicine isn't like the medicine that's practiced on TV, but there is a lot of care that's carried on under conditions of fatigue, stress, pressure to make quick decisions. Aren't all these things factors that make mistakes more likely in any work setting?

DR. NANCY DICKEY: Certainly I think if someone is in a position that they are over-fatigued or overstressed, but clearly we can't always plan medicine to occur at 8:00 A.M. when everybody is fresh on their tour of duty. So we've got to find the right mix of being able to make decisions, even when there's an unexpected crisis, but not allowing the stressors to be too great. We've begun to address that, by the way, through regulations about how many hours residents in their training years can work at a stretch, and the increased number of physician available in the work force today allows physicians to work much more predictable hours with hours of rest in between their periods of being on duty. Both of those are good for patients, but we'll never probably get to the point that every time a physician is called or is the most appropriate person to respond to an emergency, he or she has just come off of a break period. And so part of training and part of performance is being able to perform in an urgent or stressful or emergency situation.

RAY SUAREZ: A lot of the examples that were given in the report had to do with things as almost silly as bad handwriting. How do you get around that kind of thing, Dr. Dickey?

DR. NANCY DICKEY: I think Dr. Leape mentioned it. We have reasonably good evidence today that both removing the number of steps, how many people have to touch a piece of paper or an order that's being given, and changing to a computerized system, where what is put on the piece of paper is clear and easy to read, will reduce a great many of those mistakes. We're finding, a lot of doctor's offices, hospitals and other facilities are moving towards an electronic medical record. But it does bring us into Dr. Bosk's issues, because those systems are expensive. If I have to make a choice in my office between purchasing the hardware and software to have a computerized medical record versus hiring another nurse so that patients are seen in a more timely and friendly fashion, how do I make the choice? And if I'm a big hospital, we're not talking one computer, one nurse, here we're talking millions of dollars per system, and I think we have to have more evidence along Dr. Leape's line that says this is going to be cost effective before we convince hospitals, large clinics, even insurance companies that this is something they ought to pay for.

RAY SUAREZ: Well, Professor Bosk, what should the people looking at those million-dollar decision be keeping in mind at the time they have to make them?

CHARLES BOSK: Well, I think we ought to start with Dr. Leape's point, which is to get the low-hanging fruit first. That certainly makes a lot of sense. And then I think the folks that are making those decisions are really caught between the demand of employers buying health insurance to keep those costs as reasonable as possible, and then at the same time, the contradictory demand that care be as perfect as possible? I don't think yet we as a society have a good handle on how the balance those two needs. We want both, and it's very hard to have a serious discussion of how the balance those two needs together.

RAY SUAREZ: Well, Dr. Leape, as we wrap up, maybe we could talk about what happens now. I'm sure you don't want this thing collecting dust on a shelf somewhere.

DR. LUCIAN LEAPE: Not at all. And I think one of the exciting things is that the Institute of Medicine has come out and made specific recommendations about what should be done: Recommendations for health care organizations to implement some of the known safety practices, recommendations for a center for patient safety that will collect information and sponsor research, and a number of other recommendations that we hope will be picked up and acted on. I think what we've got is some momentum here. The AMA two years ago founded the National Patient Safety Foundation, which is greatly raised the awareness in medical communities. Now what we see is the Institute of Medicine saying let's move on with this. It's time to take action and not just talk about it.

RAY SUAREZ: Doctors, professor, thank you all.

CONVERSATION

JIM LEHRER: Finally tonight, the last in our series of conversations with winners of this year's National Book Awards, which were announced recently. Once again to Elizabeth Farnsworth.

ELIZABETH FARNSWORTH: The winner of the award for fiction this year is Ha Jin for his novel "Waiting." A story of old and modern China, of illusion and love, "Waiting" begins with a memorable line: "Every summer, Lin Cong returned to Goose Village to divorce his wife, Shu Yu." Ha Jin left China in 1985 to study English at Brandeis university. He began writing in English in 1987, and since then has published "Waiting," two books of poetry, two short story collections, and a novella. He is Professor of Creative Writing at Emory University in Atlanta.

Thank you for being with us, and congratulations.

HA JIN, National Book Award, Fiction: Thank you. Thank you for having me.

ELIZABETH FARNSWORTH: You joined the People's Liberation Army at age 14, then you worked for the railroad. How did you first start to study English, and why?

HA JIN: I first began studying English at age of 20 in 1966, and there was a learner program in China that started in the morning from 5:30 to 6:00 during the weekdays. And so I followed it for a year, and then when the entrance exams were restored after the Cultural Revolution, I was ready to take the exams. So I was assigned to study English at the English major.

ELIZABETH FARNSWORTH: And this is at the university level, right?

HA JIN: Yes, yes. After a year of following the learners program, then I began studying systematically as an English major.

ELIZABETH FARNSWORTH: And then you came here and you got a degree. You got a master's degree, didn't you, at Brandeis?

HA JIN: Yes.

ELIZABETH FARNSWORTH: Why did you decide to stay?

HA JIN: That was after the Tiananmen massacre. I realized that if I wanted to be a writer, I would have to stay in the states because it would be impossible for me to write honestly in Chinese in China. So it was a painful decision, but it took a year for me to decide to write English exclusively and to stay as immigrant.

ELIZABETH FARNSWORTH: Tell us very briefly the story of this novel.

HA JIN: This story is a love story in a kind of bizarre way, because this is a story about a man who is not capable of loving others. He is... Lin Cong by nature is not a passionate man, but if he were given the opportunities, he would have developed into a....maybe a normal person. But his situation, the social environment worsened his personality or character. And he is a decent man. He is a very good-hearted man. But he never maturely... he has never grown up enough to love a woman passionately.

ELIZABETH FARNSWORTH: Would you read something for us?

HA JIN: Okay. Let me read some scenes... ... we are not... the drama is not very clear if I read just one passage. Let me read some... a passage of a description of nature. I did some descriptions of nature in this book. This is about the river. "Winter in Muji was long. Snow wouldn't disappear until early May. In mid-April, when the Sung Hwa River began to break up, people would gather at the bank, watching the large blocks of ice crackling and drifting in the blackish green water. Teenage boys, baskets in hand, would tramp and hop on the floating ice, picking up pike, whitefish, carp, baby sturgeon, and catfish killed by the ice blocks that had been washed down by spring torrents. Steamboats still in the docks blew their horns time and again. When the main channel was finally clear of ice, they crept out, sailing slowly up and down the river and saluting the spectators with long blasts. Children would hail and wave at them."

ELIZABETH FARNSWORTH: Mr. Jin, I was really struck in reading your novel by the spare, very beautiful style that you achieved. And this is a style you're achieving in a language you really learned relatively recently. How do you do this?

HA JIN: Oh, perhaps because I write poetry also, and I was hired as a poet by Emory University. So I've been teaching poetry writing for years. And perhaps I was more careful with the tone and the cadence, the nuances of the language. And maybe there might be another reason, that is the story had accumulated in my mind for over a decade. So when I began to write it, a lot of things came out with some depth, I think.

ELIZABETH FARNSWORTH: The story is a story, as I understand, that you heard, or at least the broad outlines of it, in China. When you conceived it, did you conceive it in Chinese and then put it into English, or did you conceive it in English?

HA JIN: I always conceive every piece of work in English, and that's important, otherwise the feeling, the sentiment will be very different. Just the sounds of the words, the cadence, the rhythm, those things will make the prose very different. So if I put this into Chinese, it would be a different kind of book.

ELIZABETH FARNSWORTH: You said this book is about a man who, maybe given different circumstances, might have learned to love.

HA JIN: Yes.

ELIZABETH FARNSWORTH: He leaves a wife, a wife that he got through an arranged marriage, and goes with another woman, and has trouble loving her even though he had hoped he had. Is it about something larger than that, too? Is it about what conditions in China do to passionate feelings?

HA JIN: Yes, it is larger. I think it's not only about China, about Chinese. In the middle of writing this book, I was nervous, very, very nervous, worrying about the universality of the material. And then one day I came across an interview given by an American woman, a middle-aged American woman whose husband was a Navy officer. She said something really that give back my confidence. She said, "I hope... I wish my husband could have an affair with another woman so that he can prove himself capable of loving a woman passionately." Then it occurred to me that not only Chinese, there must be some American men, as well, like this. That, I think, is the essence of literature, which emphasizes the similarity, not difference.

ELIZABETH FARNSWORTH: And, Mr. Jin, how will this prize affect your future work?

HA JIN: Um, of course I can't... I don't know yet, but at this moment, there's too many calls, I guess. I'm very exhausted, but I think there will be a lot more pressure, more pressure as a writer. I have to work harder and try to really write a better book. But that's my will. Whether I can succeed at that is another question. And there might be too much self-consciousness, which can be bad for a writer.

ELIZABETH FARNSWORTH: Well, I'll hope not. Thank you so much for being with us, and congratulations again.

HA JIN: Thank you, Elizabeth.

RECAP

JIM LEHRER: Again, the major stories of this Tuesday: Protesters forced the World Trade Organization to cancel its opening ceremony in Seattle. And the FBI and Mexican authorities searched two ranches near Juarez Mexico. They said there could be 100 victims of drug violence buried there. We'll see you online and again here tomorrow evening. I'm Jim Lehrer. Thank you, and good night.